Health and Social Service Use Among Older People. The last two years of life

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Health and Social Service Use Among Older People

ACADEMIC DISSERTATION To be presented, with the permission of the board of the School of Health Sciences

of the University of Tampere, for public discussion in the Auditorium of School of Health Sciences, Medisiinarinkatu 3, Tampere, on December 9th, 2011, at 12 o’clock.

The last two years of life

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Reviewed by

Associate professor Arto Ohinmaa University of Alberta

Canada

Professor Kaisu Pitkälä University of Helsinki Finland

Distribution Bookshop TAJU P.O. Box 617

33014 University of Tampere Finland

Tel. +358 40 190 9800 Fax +358 3 3551 7685 taju@uta.fi

www.uta.fi/taju http://granum.uta.fi Cover design by

Mikko Reinikka

Page design Sirpa Randell

Acta Universitatis Tamperensis 1673 ISBN 978-951-44-8615-9 (print) ISSN-L 1455-1616

ISSN 1455-1616

Acta Electronica Universitatis Tamperensis 1137 ISBN 978-951-44-8616-6 (pdf )

ISSN 1456-954X http://acta.uta.fi

Tampereen Yliopistopaino Oy – Juvenes Print University of Tampere, School of Health Sciences Doctoral Programs in Public Health (DPPH) Finland

Supervised by

Professor Pekka Rissanen University of Tampere Finland

Professor Marja Jylhä University of Tampere Finland

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Abbreviations

ANOVA. Analysis.of.variance CI. Confidence.interval

COCTEL. Costs.of.care.towards.the.end.of.life.project HCE. Health.care.expenditure..

ICC. Intra-class.correlation

ICD-10. International.Classification.of.Diseases,.tenth.revision LOS. Length.of.stay

MOR. Median.odds.ratio MRR. Median.rate.ratio

MSAH. Ministry.of.Social.Affairs.and.Health

OR. Odds.ratio

SII. Social.Insurance.Institution

STAKES. National.Research.and.Development.Centre.for.Welfare.and.Health THL. National.Institute.for.Health.and.Welfare

TTD. Time.to.death

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List of original publications

I. Forma.L,.Rissanen.P,.Noro.A,.Raitanen.J,.Jylhä.M.(2007):.Health.

and.social.service.use.among.old.people.in.the.last.2 years.of.life..

European.Journal.of.Ageing.4:145–154..

II. Forma.L,.Rissanen.P,.Aaltonen.M,.Raitanen.J,.Jylhä.M.(2009):.Age.

and. closeness. of. death. as. determinants. of. health. and. social. care.

utilization:.a.case-control.study..European.Journal.of.Public.Health.

19:313–8.

III. Forma.L,.Jylhä.M,.Aaltonen.M,.Raitanen.J.and.Rissanen.P.(2011):.

Municipal.variation.in.health.and.social.service.use.in.the.last.two.

years.of.life.among.old.people..Scandinavian.Journal.of.Public.Health.

39:361–370.

IV. Forma. L,. Rissanen. P,. Aaltonen. M,. Raitanen. J,. Jylhä. M. (2011):.

Dementia.as.a.determinant.of.health.and.social.service.use.in.the.last.

two.years.of.life.1996–2003..BMC.Geriatrics.11:14..

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Abstract

It.is.well.known.that.older.people.use.more.health.and.social.services.than.younger.

people,. but. the. exact. determinants. of. service. use. still. remain. unclear.. More.

information.is.needed.on.whether.the.high.use.of.services.among.older.people.is.

associated.with.their.high.age.or.the.closeness.of.death,.for.instance..The.aim.of.

this.study.was.to.shed.light.on.health.and.social.service.use.among.older.people.

living.their.last.two.years.of.life.and.among.controls.who.lived.longer..Special.

consideration.was.given.to.how.age,.closeness.of.death,.municipality.of.residence.

and.dementia.diagnosis.are.associated.with.service.use.and.to.how.service.use.in.

the.last.two.years.of.life.has.changed.from.1996.to.2003.

The.services.in.focus.were.(1).hospital.inpatient.care.(2).long-term.institutional.

care. (3). regular. home. care. (at. least. once. a. week). and. (4). use. of. prescribed.

medicines..Hospital.care.included.care.provided.at.university.hospitals,.general.

hospitals.(central,.district.and.private).and.health.centre.inpatient.wards.if.length.

of.stay.was.less.than.90.days..Long-term.care.included.care.in.residential.homes.

for. older. people,. sheltered. housing. with. 24-hour. assistance. and. health. centre.

inpatient.wards.if.length.of.stay.was.90.days.or.over..The.analysis.determined.

the.probability.of.using.each.of.the.services.in.the.two-year.study.period.and.the.

number.of.days.in.care..

The.data.were.derived.from.registers.of.Statistics.Finland,.National.Institute.

for. Health. and. Welfare. and. Social. Insurance. Institute.. The. study. population.

consisted.of.all.persons.in.Finland.who.died.in.1998,.2002.or.2003.at.the.age.

of.70.years.or.over.and.a.40%.random.sample.of.those.who.died.in.1999–2001.

at.the.age.of.70.years.or.over..The.total.population.numbered.145,944.persons..

For.decedents.who.died.in.1998–2000,.a.matched.control.was.selected.who.lived.

at.least.two.years.longer..There.were.56,001.case-control.pairs,.matched.for.age,.

gender.and.municipality.of.residence..

Closeness.of.death.was.a.strong.determinant.of.hospital.and.long-term.care.

use..In.all.age.groups.decedents.used.these.services.more.often.than.their.matched.

survived.controls..The.difference.between.decedents.and.survivors.was.smaller.in.

older.than.younger.age.groups..Age.was.also.an.important.determinant.of.service.

use..Younger.people.used.hospital.care.more.often.than.older.people,.but.older.

people.used.long-term.care.more.often..

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than.the.use.of.different.types.of.hospital..Use.of.university.hospital.varied.most,.

and.there.was.also.much.variation.in.the.use.of.general.hospital.services..The.

use. of. long-term. care. and. home. care. did. not. vary. between. hospital. districts..

Municipal.differences.in.the.use.of.home.care.services.were.greater.than.in.the.

use.of.long-term.institutional.care..The.proportion.of.service.users.varied.more.

than.the.number.of.days.in.care.among.users..Municipal.level.variables.did.not.

explain.much.of.the.differences..

Older. people. with. a. dementia. diagnosis. were. more. than. nine. times. more.

likely.to.use.long-term.care.than.people.without.a.dementia.diagnosis..The.use.of.

hospital.care,.on.the.other.hand,.was.more.common.among.older.people.without.

dementia,.even.when.comorbidity.was.adjusted.for..Among.users.the.number.of.

days.in.care.was.higher.for.people.with.a.dementia.diagnosis..The.use.of.university.

hospital.and.long-term.care.increased.during.the.study.period.from.1996.to.2003,.

while.the.use.of.general.hospital.and.home.care.decreased..The.number.of.days.

in. care. increased. on. health. centre. inpatient. wards. and. in. long-term. care,. but.

decreased.in.general.hospitals..

In.conclusion,.closeness.of.death.is.an.important.determinant.of.health.and.

social.service.use.among.older.people..However,.the.effect.of.closeness.of.death.

varies.with.age.and.between.different.services..Age.also.has.an.impact.on.service.

use.among.older.people.at.the.end.of.life..Further.research.is.needed.to.determine.

whether.older.people.living.in.different.municipalities.as.well.as.those.with.and.

without.a.dementia.diagnosis.have.equal.access.to.care.

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Tiivistelmä

Vanhojen.ihmisten.tiedetään.käyttävän.sosiaali-.ja.terveyspalveluita.enemmän.

kuin.nuorempien..Palvelujen.käytön.taustalla.olevia.tekijöitä.ei.kuitenkaan.tun- neta.tarkasti,.esim..missä.määrin.vanhojen.ihmisten.suurempi.palvelujenkäyttö.

liittyy.heidän.korkeaan.ikäänsä.ja.missä.määrin.siihen,.että.he.ovat.lähellä.kuo- lemaa..Tutkimuksen.tarkoituksena.oli.tuottaa.tietoa.vanhojen.ihmisten.sosiaali-.

ja.terveyspalvelujen.käytöstä.kahtena.viimeisenä.elinvuotena.ja.niiden.joukossa,.jotka.elivät.pidempään..Erityisesti.tutkittiin,.miten.ikä,.kuoleman.läheisyys,.

kotikunta.ja.dementiadiagnoosi.ovat.yhteydessä.palvelujenkäyttöön,.sekä.miten.

käyttö.kahtena.viimeisenä.elinvuotena.muuttui.vuodesta.1996.vuoteen.2003..

Tutkitut.palvelut.olivat.(1).vuodeosastohoito.sairaalassa.(2).pitkäaikainen.lai- toshoito.(3).säännöllinen.kotihoito.(vähintään.kerran.viikossa).ja.(4).reseptilääk- keiden.käyttö..Sairaalat.olivat.yliopisto-,.ja.yleissairaala.(keskus-,.alue-.ja.yksityi- nen.sairaala).sekä.terveyskeskuksen.vuodeosasto,.jos.hoitopäiviä.oli.vähemmän.

kuin.90..Pitkäaikaishoitoa.olivat.vanhainkoti,.tehostettu.palveluasuminen.ja.terveyskeskuksen.vuodeosasto,.jos.hoitopäiviä.oli.90.tai.enemmän..Tutkimuksessa.

analysoitiin.1).käyttikö.henkilö.kyseistä.palvelua.vähintään.kerran.tutkimusai- kana.(käytön.todennäköisyys).ja.2).kuinka.monta.päivää.henkilö.vietti.kyseisessä.

hoitopaikassa..

Tutkimuksen.aineisto.poimittiin.Tilastokeskuksen,.Terveyden.ja.hyvinvoin- nin.laitoksen.sekä.Kansaneläkelaitoksen.rekistereistä..Tutkimusjoukkoon.kuu- luivat.kaikki.vuosina.1998,.2002.tai.2003.70-vuotiaana.tai.vanhempana.kuolleet.

suomalaiset.sekä.40.prosentin.satunnaisotos.vuosina.1999–2001.70-vuotiaana.tai.

vanhempana.kuolleista.suomalaisista,.yhteensä.145 944.henkilöä..Vuosina.1998–

2000. kuolleille. poimittiin. iän,. sukupuolen. ja. kotikunnan. mukaan. kaltaistettu.

verrokki,.joka.oli.elänyt.vähintään.kaksi.vuotta.pariaan.pidempään..Kaltaistettu- ja.tapaus–verrokki-pareja.oli.56 001...

Kuoleman. läheisyys. määritti. sairaalan. ja. pitkäaikaishoidon. käyttöä. voi- makkaasti..Kaikissa.ikäryhmissä.ne,.jotka.elivät.kahta.viimeistä.elinvuottaan,.

käyttivät.enemmän.palveluja.kuin.heidän.kaltaistetut.verrokkinsa,.jotka.elivät.

pidempään..Ero.tapausten.ja.verrokkien.välillä.oli.pienempi.vanhimmassa.kuin.

nuoremmissa.ikäryhmissä..Myös.ikä.oli.tärkeä.palvelujenkäyttöä.määrittävät.te-

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män.pitkäaikaista.laitoshoitoa..

Sairaalan.käyttö.kokonaisuutena.vaihteli.kuntien.ja.sairaanhoitopiirien.välillä.

vähemmän.kuin.käytetty.sairaalatyyppi..Yliopistosairaalan.käyttö.vaihteli.eni- ten,.ja.myös.yleissairaalan.käytön.vaihtelu.oli.suurta..Pitkäaikaishoidon.ja.kotihoidon.käyttö.eivät.vaihdelleet.tilastollisesti.merkitsevästi.sairaanhoitopiirien.

välillä..Kotihoidon.käyttö.vaihteli.enemmän.kuntien.välillä.kuin.pitkäaikaishoi- don.käyttö..Palvelua.käyttäneiden.osuus.vaihteli.enemmän.kuntien.ja.sairaanhoitopiirien.välillä.kuin.hoitopäivien.määrä.palvelua.käyttäneillä..Kuntien.ominai- suudet.eivät.juuri.selittäneet.palvelujen.käytön.eroja...

Vanhat.ihmiset,.joilla.oli.dementia-diagnoosi,.käyttivät.pitkäaikaishoitoa.yli.

yhdeksän.kertaa.todennäköisemmin.kuin.ne,.joilla.ei.ollut.dementia-diagnoosia..

Sairaalan.käyttö.sen.sijaan.oli.yleisempää.niiden.joukossa,.joilla.ei.ollut.dementiaa,.vaikka.muu.sairastavuus.oli.vakioitu..Palvelua.käyttäneiden.joukossa.dementiaa.sairastavilla.oli.enemmän.hoitopäiviä.kuin.ei-sairastavilla..Yliopistosairaalan.

ja.pitkäaikaishoidon.käyttö.yleistyi.tutkimusjakson.aikana.(1996–2003),.kun.taas.

yleissairaalan.ja.kotihoidon.käyttö.väheni..Hoitopäivien.määrä.kasvoi.terveyskeskuksen.vuodeosastolla.ja.pitkäaikaishoidossa.mutta.väheni.yleissairaalassa..

Yhteenvetona.voidaan.todeta,.että.kuoleman.läheisyys.on.tärkeä.sosiaali-.ja.

terveyspalvelujen.käyttöä.määrittävä.tekijä..Kuoleman.läheisyyden.vaikutus.on.

kuitenkin.erilainen.eri-ikäisillä.ja.eri.palveluissa..Myös.ikä.vaikuttaa.vanhojen.

ihmisten. palvelujen. käyttöön. kahtena. viimeisenä. elinvuotena.. Jatkossa. pitäisi.

tutkia,.miten.tasa-arvo.hoitoon.pääsyssä.toteutuu.eri.kunnissa.asuvien.vanhojen.

ihmisten.kesken.ja.dementiaa.sairastavien.ja.ei-sairastavien.kesken..

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1 Introduction

Old.people.use.health.and.social.services.more.than.younger.people.do..They.

have. more. diseases. and. functional. impairments. than. younger. people,. and.

therefore.need.care.to.compensate.for.the.disability.as.well.as.treatment.for.the.

disease..The.population.in.Finland.is.getting.older,.with.both.absolute.numbers.

and.the.proportion.of.older.people.increasing.rapidly;.this.is.particularly.true.

of.the.oldest.old.(85.years.or.over).(Official.Statistics.of.Finland,.2009)..These.

trends.are.expected.to.bring.a.sharp.increase.in.health.and.social.service.use.and.

expenditure.in.the.near.future..

In.order.that.the.health.and.social.service.system.can.properly.respond.to.the.

needs.of.the.ageing.population,.it.needs.to.have.access.to.detailed.information.

about.the.determinants.of.service.use..There.are.at.least.two.possible.explanations.

for.the.observation.that.service.use.is.more.common.among.older.people.than.

among. younger. people:. either. because. they. are. old,. or. because. they. are. near.

death..The.use.and.costs.of.health.and.social.services.have.found.to.be.high.in.the.

last.phase.of.life.in.all.ages.(Jakobsson,.Bergh,.Ohlen,.Oden,.&.Gaston-Johansson,.

2007),.but.there.is.also.evidence.of.differences.between.age.groups.in.levels.of.

service.use.(Busse,.Krauth,.&.Schwartz,.2002)..End.of.life.in.old.age.is.usually.

marked.by.disease.and.disability,.and.service.use.can.be.expected.to.accumulate.

in.the.last.years.of.life..

This.study.builds.on.earlier.research.analysing.the.red.herring.hypothesis.and.

high.costs.of.dying,.which.has.highlighted.the.effect.of.closeness.of.death.on.the.

use.and.costs.of.health.services.(e.g..Lubitz.&.Prihoda,.1984;.Zweifel,.Felder,.&.

Meiers,.1999)..However,.there.is.lack.of.evidence.on.the.role.of.age.and.closeness.

of.death.in.the.use.of.different.types.of.health.and.social.services..This.study.is.

concerned.with.health.and.social.service.use.among.older.people..The.focus.is.on.

service.use.in.the.last.two.years.of.life.and.on.the.differences.in.service.use.between.

those.living.their.last.two.years.of.life.and.those.living.longer..The.associations.of.

age,.closeness.of.death,.municipality.of.residence,.dementia.diagnosis.and.year.of.

death.with.service.use.among.older.people.are.studied.in.more.detail..

This.study.applies.the.concepts.and.methods.of.health.economics.and.health.

services.research.in.the.context.of.care.for.older.people.(70.years.or.older)..A.

proper.understanding.of.the.mechanisms.underlying.health.and.social.service.

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use.among.older.people.requires.the.simultaneous.application.of.many.research.

disciplines,. not. only. health. sciences. but. also. such. fields. as. gerontology. and.

demography..

The. study. was. conducted. as. part. of. the. COCTEL. project. (Costs. Of. Care.

Towards.the.End.of.Life),.which.is.concerned.with.the.effects.of.age,.closeness.

of.death.and.regional.factors.on.health.and.social.service.use.as.well.as.with.the.

costs.and.pathways.of.care..

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2 Background

2.1 Ageing of population

The.Finnish.population.is.rapidly.getting.older,.with.both.the.absolute.and.relative.

number.of.older.people.rising.sharply.(Figure.1)..A.major.new.characteristic.of.the.

present.population.is.the.lengthening.of.old.age,.i.e..decreasing.old.age.mortality..

In.20.years,.from.1989.to.2009,.life.expectancy.in.Finland.at.age.70.has.increased.

from.13.8.to.17.0.years.among.women.and.from.10.9.to.13.7.years.among.men,.and.

at.age.80.from.7.5.to.9.4.years.among.women.and.from.6.2.to.7.6.years.among.men.

(Official.Statistics.of.Finland,.2010)..In.most.developed.countries.life.expectancy.

has. increased. almost. linearly,. and. this. trend. is. expected. to. continue. (Oeppen.

&.Vaupel,.2002;.Olshansky,.Goldman,.Zheng,.&.Rowe,.2009),.although.not.all.

scholars.agree.(Olshansky.et.al.,.2005)...

Population. ageing. imposes. a. host. of. challenges. for. society.. Most. notable.

among.these.challenges.are.the.provision.of.income.transfers.and.the.delivery.

of.health.and.social.services.for.older.people..Income.transfers.account.for.the.

figure 1. People aged 65 years or more as a proportion of the finnish population from 1900 to 2010 and projection until 2060. Breakdown for age groups 65 or over and 80 or over provided from 2010 (Official Statistics of finland, 2009).

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largest.proportion.of.old-age.expenditure.(16.3.billion.euro.in.2008),.from.which.

services.for.older.people.accounted.for.11.6%.(National.Audit.Office.of.Finland,.

2010)..Health.and.social.service.expenditure.starts.to.increase.sharply.on.average.

at.the.age.of.70.years.(National.Research.and.Development.Centre.for.Welfare.

and.Health,.2006)..In.the.age.group.80-84.years,.for.instance,.health.expenditure.

is.four.times.and.social.service.expenditure.up.to.20.times.higher.than.in.the.age.

group.30–34.years.(Heikkilä,.2007)..

Need for health and social services among older people

The.need.for.health.and.social.services.among.older.people.is.often.due.to.disability.

and.comorbidity.(van.Weel.&.Michels,.1997)..It.has.been.reported.that.the.need.

for.regular.help.(formal.or.informal).starts.to.increase.after.age.75.(Voutilainen.et.

al.,.2007)..According.to.the.findings.of.Vaarama.(2004),.one.in.six.persons.aged.

65,.one.in.three.persons.aged.75.and.every.other.person.aged.85.needed.help.on.

a.daily.basis.

The.results.on.the.development.of.disability.vary.or.are.even.reversed.between.

age. groups. and. between. different. studies.. Nationally. representative. data. from.

Finland.and.other.countries.indicate.decreasing.disability.for.those.aged.80.or.

younger.from.1993.to.2005.(Sulander,.Puska,.Nissinen,.Reunanen,.&.Uutela,.2007).

and.from.1978–1980.to.2000–2001.(Lafortune,.Balestat,.&.Disability.Study.Expert.

Group.Members,.2007;.Martelin,.Sainio,.&.Koskinen,.2004)..The.trends.among.

the.oldest.old.have.been.different:.Sarkeala,.Nummi,.Vuorisalmi,.Hervonen.and.

Jylhä.(2011).found.that.the.level.of.disability.among.people.aged.90.years.or.over.

in.Finland.was.unchanged.from.2001.to.2007..From.1978–1980.to.2000–2001,.

self-care.ability.and.mobility.decreased.among.people.aged.85.years.or.more.in.

the.study.of.Martelin.et.al..(2004),.and.no.decrease.was.seen.in.the.prevalence.

of.disability.among.people.aged.85.years.or.more.(Lafortune.et.al.,.2007)..In.the.

USA.the.percentage.of.older.people.with.mobility.difficulty.was.shown.to.have.

increased.markedly.from.1998.to.2006.in.all.ages,.but.most.steeply.among.people.

aged.80.or.over.(Crimmins.&.Beltran-Sanchez,.2011).

The. likelihood. of. comorbidity. and. functional. decline. increases. with. age,.

which. means. that. the. need. for. services. differs. between. age. groups.. However,.

epidemiological. studies. indicate. that. older. people. in. their. last. years. of. life.

experience. a. steeper. decline. in. functional. status. than. do. same-age. survivors.

(Guralnik,.LaCroix,.Branch,.Kasl,.&.Wallace,.1991;.Wolinsky,.Stump,.Callahan,.

&.Johnson,.1996),.and.among.older.people.it.is.the.oldest.(85.years.or.over).who.

are.more.likely.to.experience.a.longer-term.disability.before.death.(Lunney,.Lynn,.

Foley,. Lipson,. &. Guralnik,. 2003).. Functional. decline. before. death. also. differs.

by.age,.being.greater.with.more.advanced.age.at.death.(Guralnik.et.al.,.1991)..

Diehr,. Williamson,. Burke. and. Psaty. (2002). examined. the. associations. of. the.

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ageing.process.and.the.dying.process.with.changes.in.health.variables.such.as.

self-rated.health,.activities.of.daily.living.(ADL),.instrumental.activities.of.daily.

living.(IADL),.bed.days,.walking.speed.and.hospital.use..They.found.that.the.

effect.of.the.dying.process.on.all.variables.was.substantially.larger.than.the.effect.

of.ageing..No.age.effect.was.seen.for.hospital.use..

The. prevalence. of. diseases. in. the. old. population. has. increased. over. time.

(Christensen,.Doblhammer,.Rau,.&.Vaupel,.2009;.Crimmins.&.Beltran-Sanchez,.

2011)..People.today.live.longer.with.their.diseases..They.are.more.aware.of.them.

and. get. treatment. for. them. more. often.. The. time. trend. of. the. prevalence. of.

dementia.and.low.cognitive.function.among.older.people.is.not.clear..The.results.

depend.upon.the.exact.diagnosis.and.also.vary.between.persons.with.diagnosis.

and.measured.lower.cognitive.functioning..In.Finland.dementia.has.become.an.

increasingly.common.cause.of.death:.in.the.space.of.two.decades.the.numbers.

have.more.than.doubled.(Statistics.Finland,.2010)..

Development of health and functional ability

The.effects.of.population.ageing.on.the.need.for.health.and.social.services.depend.

ultimately.on.the.health.of.older.people..The.relationship.between.age.and.service.

use.is.not.constant,.nor.will.it.be.constant.in.the.future.(National.Research.and.

Development.Centre.for.Welfare.and.Health,.2006)..It.has.been.predicted.that.the.

number.of.people.with.limited.mobility.will.increase.by.70%.from.2000.to.2030.if.

their.age-group.specific.proportions.remain.the.same.as.in.1980-2000..However.

if.functional.ability.continues.to.improve.at.the.same.pace,.the.number.of.people.

with. disability. will. increase. much. more. slowly,. by. about. half. that. number.

(Martelin.et.al.,.2004)..In.this.case.the.need.for.health.and.social.services.would.

increase.more.slowly.than.population.ageing.gives.reason.to.assume..Nonetheless.

the. number. of. people. aged. 75. or. older. with. disabilities. has. continued. to. rise.

sharply,.despite.the.trends.for.the.proportion.of.the.disabled..In.the.future.it.is.

possible.that.the.favourable.trends.in.functional.ability.will.reduce.the.need.for.

services.at.least.among.those.aged.80.or.younger..However,.there.is.no.evidence.of.

improving.functional.ability.in.the.age.groups.85-90.years.or.over,.where.service.

needs.are.highest..

Life.expectancy.can.be.divided.into.healthy.and.unhealthy.life-years,.during.

which.needs.for.services.vary..Christensen.et.al..(2009).concluded.that.people.

today. are. living. longer. than. previously,. and. that. they. are. living. longer. with.

less.disability.and.fewer.functional.limitations..However,.not.all.the.empirical.

evidence. supports. this.. Many. studies. have. reported. greater. improvements. in.

disability-free.life.expectancy.(healthy.life.years,.HLY).than.in.life.expectancy.

(Crimmins,.2004;.Jeune.&.Bronnum-Hansen.H.,.2008;.Van.Oyen,.Cox,.Demarest,.

Deboosere,.&.Lorant,.2008)..In.the.UK,.by.contrast,.it.has.been.reported.that.HLY.

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has. increased. less. than. life. expectancy. (Bebbington. &. Comas-Herrera,. 2000)..

These.discrepancies.may.be.due.to.differences.in.ways.of.measuring.disability.

(McNamee.&.Stearns,.2003)..

There.are.at.least.three.hypotheses.regarding.how.increased.life.expectancy.

is. associated. with. morbidity.. The. extreme. hypotheses. are. compression. and.

expansion. of. morbidity.. Fries. (2002). (first. published. in. 1980). assumed. that.

although.the.average.length.of.life.had.increased,.the.maximum.length.of.life.had.

not..In.the.future,.however,.the.amount.of.time.people.spend.in.poor.health.will.

be.shorter.and.compressed.to.the.end.of.life;.hence.the.theory.of.compression.of.

morbidity..Gruenberg.(2005).(first.published.in.1977).assumed.that.age-specific.

risks.for.poor.health.are.constant,.but.the.survival.of.frail.old.people.will.increase,.

which.will.then.lead.to.an.expansion.of.morbidity..The.third.hypothesis.is.called.

dynamic. equilibrium. (Manton,. 1982):. longevity. increases. both. the. number. of.

years.that.people.spend.in.good.and.poor.health,.but.the.conditions.suffered.in.

poor.health.will.be.less.serious..

The.empirical.results.testing.the.hypotheses.are.contradictory..Cai.and.Lubitz.

(2007).found.an.increase.in.active.life.years.(ALE).and.a.decrease.in.life.expectancy.

among.old.Americans.with.severe.disability.from.1992.to.2003..These.findings.

were.consistent.with.certain.elements.of.the.theories.of.compression.of.morbidity.

and.dynamic.equilibrium..The.findings.of.Crimmins.and.Beltran-Sanchez.(2011).

did.not.support.the.compression.of.morbidity.hypothesis.in.the.USA..In.their.

review.Robine,.Saito.and.Jagger.(2009).found.no.strong.evidence.of.compression.

of.morbidity.in.countries.with.the.lowest.mortality.rates..

Population ageing and health expenditure

Although.the.evidence.suggests.that.health.care.expenditure.is.higher.for.older.

people.than.for.younger.individuals.(micro.level),.it.is.not.clear.whether.population.

ageing.will.increase.aggregate.costs.at.macro.level.(Chernichovsky.&.Markowitz,.

2004;.Getzen,.1992)..Total.expenditure.will.grow.rapidly.if.demographic.trends.

combine. with. rising. per. capita. expenditure. (Garber,. MaCurdy,. &. McClellan,.

1999).. However,. the. increasing. number. of. older. people. will. not. necessarily.

increase.health.expenditure.per.capita..Lubitz,.Beebe.and.Baker.(1995).reported.

that.lifetime.Medicare¹.payments.were.higher.for.those.who.lived.longer,.but.the.

payments.associated.with.an.additional.year.of.life.decreased.with.increasing.age.

at.death..There.are.also.results.indicating.that.the.share.of.total.health.expenditure.

1. Medicare.is.a.health.insurance.programme.in.the.USA..It.is.intended.for.people.aged.

65.or.older.and.people.under.age.65.with.certain.disabilities..Part.A.Hospital.Insurance.

helps. to. cover. inpatient. care. in. hospitals. and. skilled. nursing. facilities. (not. long-term.

care),.hospice.care.and.some.home.care..Part.B.Medical.Insurance.helps.to.cover.doctor’s.

services.and.outpatient.care.(Centers.for.Medicare.and.Medicaid.services,.2005)..

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allocated.to.the.population.aged.65.and.over.has.decreased,.for.instance.in.England.

and.Wales.from.40%.in.1985-87.to.35%.1996-99.(Seshamani.&.Gray,.2002)..

Population.ageing.is.not.the.only.and.not.even.the.most.important.driver.of.

health.care.expenditure..In.OECD.countries.the.age.effect.accounted.for.less.than.

one-tenth.of.the.growth.of.health.expenditure.between.1970.and.2002.(OECD,.

2006)..Dormont,.Grignon.and.Huber.(2006).studied.the.effect.of.demographic.

change,.changes.in.morbidity.and.changes.in.care.practices.on.the.increase.in.

health.expenditure.from.1992.to.2000.in.France.and.concluded.that.ageing.had.a.

relatively.minor.impact.on.rising.HCE..The.impact.of.changes.in.care.practices.

was.3.8.times.higher,.and.changes.in.morbidity.induced.savings.which.more.than.

offset.the.increase.due.to.population.ageing..The.effect.of.changes.in.practices.

was. particularly. pronounced. in. the. use. of. medicines.. Earlier. Chernichovsky.

and.Markowitz.(2004).and.Getzen.(1992).found.that.population.ageing.is.not.a.

significant.cause.of.rising.health.care.costs,.but.increasing.GDP.and.per.capita.

income.emerged.as.statistically.significant.predictors.

Projections

Some.projections.have.been.made.to.evaluate.the.impact.of.population.ageing.on.

health.and.social.service.use.and.expenditure..The.results.of.these.projections.

vary.because.of.their.different.background.assumptions.and.because.they.cover.

different.sets.of.expenditures.(National.Research.and.Development.Centre.for.

Welfare. and. Health,. 2006).. Many. forecasts. are. based. on. current. health. and.

social.expenditure.in.different.age.groups,.which.are.then.projected.according.

the.expected.population.trends.(National.Research.and.Development.Centre.for.

Welfare.and.Health,.2006)..In.other.words.they.ignore.possible.future.changes.

in.morbidity.and.disability.among.older.people.(Lassila.&.Valkonen,.2011)..Räty,.

Luoma,.Mäkinen.and.Vaarama.(2003).assumed.that.increasing.life.expectancy.

will.shift.the.focus.of.demand.for.services.by.one.year.over.every.ten.years,.and.

Vaarama.and.Voutilainen.(2002).took.into.account.the.current.service.structure.

recommendations. and. assumed. changes. in. service. demand. and. efficiency..

However,.the.projections.are.affected.by.a.host.of.other.factors.as.well,.including.

changes.in.the.way.services.are.organized.and.delivered,.the.prices.of.services,.the.

development.of.health.and.functional.status,.and.labour.productivity..

In.Finland.several.research.institutes.have.projected.that.the.strongest.increase.

in.health.and.social.service.use.and.expenditure.will.be.seen.from.2010.to.2030..

This.growth.is.forecast.to.continue.from.2030.through.to.2050,.but.it.will.be.

steadier.(Lassila.&.Valkonen,.2002;.National.Research.and.Development.Centre.

for.Welfare.and.Health,.2006;.Räty.et.al.,.2003)..It.is.thought.that.the.growth.

of.social.care.expenditure.is.primarily.explained.by.the.increasing.use.of.home.

care.and.other.services.for.older.people,.while.the.growth.of.health.expenditure.

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is.additionally.explained.by.the.development.of.technology.(Ministry.of.Social.

Affairs. and. Health,. 2002).. The. main. factors. underlying. the. increase. in. social.

expenditure.are.assumed.to.be.earnings-related.pensions,.health.care.and.care.for.

older.people.(Lassila.&.Valkonen,.2002)..

Since.it.has.been.shown.that.health.care.expenditure.increases.substantially.

with.the.approach.of.death.and.that.the.effect.of.age.is.reduced.when.controlling.

for.time.to.death,.some.projections.have.also.taken.into.account.time.to.death..

Häkkinen,. Martikainen,. Noro,. Nihtilä. and. Peltola. (2008). projected. health.

expenditure.from.2016.to.2036,.firstly,.by.using.a.naïve.model.(including.age,.

gender.and.their.interactions);.secondly,.by.taking.into.account.the.proximity.

of.death;.and.thirdly,.by.assuming.an.improvement.in.the.functional.capacity.

of.older.people.so.that.need.for.long-term.institutional.care.would.be.delayed.by.

three.years..The.second.model.gave.a.13%.lower.projection.for.total.expenditure.

in.2036.than.the.naïve.model,.and.the.third.model.a.22%.lower.projection.than.

the.naïve.model.(Häkkinen.et.al.,.2008)..

Similar.effects.have.been.found.in.projections.made.in.different.countries..In.

the.USA,.naïve.models.overestimated.predicted.lifetime.health.expenditure.by.

9-15%.(depending.on.the.longevity.assumption).over.a.20-year.forecast.period.

(Stearns.&.Norton,.2004)..A.naïve.method.indicated.22.5%.higher.future.health.

care.costs.than.an.improved.method.that.took.into.account.the.proximity.of.death.

in.Denmark.from.1995.to.2020.(Serup-Hansen,.Wickstrøm,.&.Kristiansen,.2002)..

Seshamani.and.Gray.(2004b).projected.that.the.real.average.age-specific.per.capita.

costs.of.the.old.population.will.decrease.from.2002.to.2026..Aggregate.hospital.

costs. will. therefore. be. much. lower. than. indicated. by. naïve. models.. However,.

Breyer.and.Felder.(2006).concluded.that.excluding.the.effect.of.costs.of.dying.on.

HCE.leads.to.a.smaller.error.than.underestimating.the.financial.consequences.of.

expanding.medical.technology..

2.2 Red herring hypothesis

“Red.herring”.refers.to.a.false.lead.which.points.in.one.direction.when.in.fact.the.

truth.lies.somewhere.else..In.the.context.of.health.economics,.the.red.herring.

hypothesis.means.that.while.it.is.assumed.that.the.main.driver.of.the.use.and.costs.

of.health.and.social.services.among.older.people.at.the.individual.level.is.age,.the.

real.reason.is.the.closeness.of.death.(or.time-to-death,.TTD)..The.hypothesis.is.

interpreted.to.imply.that.population.ageing.will.not.have.such.a.great.impact.on.

health.care.use.and.costs.in.the.future.because.the.most.expensive.phase.of.life.

will.not.necessarily.lengthen..

The. red. herring. hypothesis. was. first. tested. and. named. by. Zweifel. et. al..

(1999)..Before.them,.research.was.concerned.to.explore.the.“high.costs.of.dying”..

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Lubitz.and.Prihoda.(1984).found.that.28%.of.Medicare.expenditure.in.1978.was.

attributable.to.5.9%.of.beneficiaries.who.died.in.that.year,.and.they.concluded.that.

the.higher.costs.of.health.care.at.older.ages.were.largely.due.to.higher.mortality..A.

similar.result.was.reported.ten.years.later.by.Temkin-Greener,.Meiners,.Petty.and.

Szydlowski.(1992).and.in.2002.in.the.UK,.where.decedents.comprised.1%.of.the.

population.and.accounted.for.28.9%.of.total.hospital.expenditures.(Seshamani.

&.Gray,.2004b)..Riley.and.Lubitz.(2010).found.that.the.proportion.of.Medicare.

spending.on.those.who.were.living.their.last.years.of.life.declined.slightly.from.

1978.to.2006,.but.after.adjusting.for.age,.sex.and.death.rates,.the.trend.was.not.

significant..The.“high.costs.of.dying”.findings.has.provoked.discussion.about.

wasteful.resource.use.on.dying.persons.as.well.as.claims.about.overly.intensive.

treatments.and.heroic.efforts.to.save.lives,.but.there.is.no.evidence.to.back.up.

these.claims.(see.e.g..Lubitz.&.Prihoda,.1984;.McCall,.1984;.Scitovsky,.2005)..

Zweifel.et.al..(1999).tested.two.hypotheses:.Does.HCE.during.the.last.years.

of. life. increase. as. a. function. of. closeness. to. death. (hypothesis. D),. or. does. it.

increase.as.a.function.of.age.(hypothesis.A)?.This.test.allows.for.conclusions.to.

be.drawn.about.the.future.growth.of.HCE..If.A.is.accepted,.population.ageing.

will.drive.up.per.capita.HCE;.if.D.is.accepted,.ageing.cannot.be.a.principal.cost.

driver.at.the.level.of.the.individual..However,.when.the.number.of.persons.in.

their.last.two.years.of.life.increases.as.a.proportion.of.the.population,.HCE.will.

also.increase..The.results.lend.strong.support.to.hypothesis.D:.no.correlation.was.

found.between.age.and.HCE.for.older.people..In.the.last.three.months.of.life.

HCE.was.several.times.higher.(307%.and.218%.in.different.samples).than.in.the.

three-month.period.two.years.before.death..The.last.phase.of.life.was.costly.in.all.

old.ages.(Zweifel.et.al.,.1999)..These.findings.have.subsequently.been.confirmed:.

proximity.to.death.increases.hospital.costs.more.than.age.(Häkkinen.et.al.,.2008;.

Hashimoto,.Horiguchi,.&.Matsuda,.2010;.Seshamani.&.Gray,.2004c)..When.the.

importance.of.time.to.death.was.recognized,.models.that.excluded.this.factor.

became.known.as.naïve.(Werblow,.Felder,.&.Zweifel,.2007)..

The. red. herring. hypothesis. was. first. tested. in. the. context. of. health. care.

expenditure.and.hospital.use.and.later.in.the.context.of.long-term.care.and.other.

services.. Norton. (2000). suggested. that. long-term. care. expenditure. increases.

with.age,.but.acute.medical.expenses.do.not..Yang,.Norton.and.Stearns.(2003).

concluded. that. closeness. of. death. was. the. main. reason. for. higher. hospital.

inpatient.costs,.while.age.was.the.main.reason.for.higher.long-term.care.costs..

The.authors.of.the.original.red.herring.paper.later.expanded.their.hypothesis.to.

apply.to.other.services.as.well.(Werblow.et.al.,.2007)..They.found.that.not.age.but.

proximity.to.death.was.affecting.the.use.and.costs.of.all.other.services,.while.age.

had.a.significant.positive.effect.on.long-term.care.(institutional.and.home.care)..

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However.proximity.to.death.was.also.an.important.determinant.of.the.use.of.

long-term.care.services..

The. original. red. herring. paper. by. Zweifel. et. al.. (1999). has. subsequently.

been.widely.revisited.and.criticized..Getzen.(2001).pointed.out.that.Zweifel.et.

al..failed.to.include.survivors.and.persons.younger.than.65.years.and.that.they.

derived.macroeconomic.variables.simply.from.micro.level.findings..In.addition,.

it.has.been.found.that.studies.testing.the.red.herring.hypothesis.are.susceptible.

to. endogeneity:. health. care. expenditure. (HCE). is. explained. by. TTD,. but. on.

the.other.hand.HCE.may.also.affect.TTD.(McNamee.&.Stearns,.2003;.Salas.&.

Raftery,.2001)..Zweifel,.Felder.and.Meier.(2001).argued.that.the.endogeneity.claim.

was.not.supported.by.the.available.empirical.evidence..Later.on.they.found.that.

endogeneity.does.in.fact.exist:.HCE.has.a.positive.effect.on.TTD,.except.during.

the. last. month. before. death. (Felder,. Werblow,. &. Zweifel,. 2010).. Still,. the. core.

results.that.TTD.rather.than.age.determines.HCE.were.confirmed..

Seshamani.and.Gray.(2004a).tested.the.results.of.Zweifel.et.al..(1999).with.

their.own.data.and.argued.that.the.Heckman.selection.model.used.by.Zweifel.

et.al..showed.that.neither.age.nor.closeness.of.death.have.a.significant.effect.on.

hospital.costs..They.demonstrated.econometric.problems.and.preferred.to.use.a.

more.robust.two-part.model,.with.which.they.proceeded.to.conclude.that.both.

age.and.proximity.of.death.have.effects.on.hospital.costs..However,.the.effect.

of.age.was.smaller.than.that.of.proximity.of.death.(Seshamani.&.Gray,.2004a)..

Salas.and.Raftery.(2001).also.criticized.the.correction.of.selection.bias.used.in.the.

Heckman.model.for.potential.multicollinearity...

2.3 Basic concepts

Health.economics.comprises.two.main.themes,.viz..equity.and.efficiency..This.

study.is.concerned.with.the.equity.theme,.i.e..with.how.health.and.social.services.

are.distributed.among.older.people..The.view.is.positive.rather.than.normative:.

the.aim.is.to.answer.the.question.of.how.services.are.distributed,.not.to.establish.

how. they. should. be. distributed.. Resources. are. always. scarce. in. relation. to.

unlimited. needs. (regardless. of. whether. the. population. is. ageing),. and. choices.

regarding.allocation.have.to.be.made..Opportunity.cost.of.the.service.is.the.utility.

that.would.be.obtained.from.the.best.alternative.use.of.resources..

This.study.is.concerned.to.describe.and.analyse.the.use.of.health.and.social.

services..Service.use.takes.place.when.demand.meets.supply.(Figure.2)..Demand.

is.derived.from.need,.from.the.individual’s.interpretation.that.certain.symptoms.

call.for.services..Demand.is.also.preceded.by.the.individual’s.desire.for.services..

Needs.and.desires.are.unlimited,.whereas.resources.are.limited,.and.the.individual.

will.aim.to.choose.the.option.that.they.believe.will.give.the.highest.utility..

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Need.has.been.defined.as.the.ability.to.benefit:.need.is.the.ability.of.individuals.or.

groups.to.benefit.from.the.consumption.of.health.care,.where.benefit.is.measured.

in.terms.of.health.improvements.(Culyer,.1991)..Another.way.of.defining.need.

is.to.suggest.that.the.needed.entity.(1).is.actually.necessary.and.(2).it.ought.to.

be.received.(Culyer,.2005)..In.health.care.contexts.individuals.do.not.necessarily.

know.what.their.needs.are.nor.what.the.costs.and.utilities.of.care.are..Therefore.

health.professionals.have.an.important.role.in.decisions.about.the.use.of.services..

Demand. expresses. the. quantity. of. commodity. that. the. buyer. wishes. to.

purchase.at.current.prices,.and.supply.the.quantity.of.commodity.that.sellers.are.

willing.to.sell.at.current.prices..In.health.and.social.care.markets.the.impact.of.

prices.and.the.roles.of.purchaser.and.seller.are.less.clear..

Demand.for.health.care.is.irregular.and.unpredictable.(Arrow,.1963)..In.the.

field.of.health.care.it.is.possible.to.distinguish.at.least.three.kinds.of.demand:.

demand.for.health,.demand.for.health.care.or.services.(which.is.derived.from.

demand. for. health). and. supplier-induced. demand. (SID).. SID. arises. from. the.

asymmetric.information.between.physician. (or.other.health.care. professional).

and.patient,.when.the.physician.is.in.the.position.to.influence.the.demand.for.his.

own.services.(Evans,.1991).(Figure.2).

It.has.been.suggested.that.demand.for.long-term.care.is.fundamentally.different.

in.nature.from.demand.for.other.health.services..Long-term.care.is.designed.for.

the.care.for.chronic.illness.or.disability,.and.the.length.of.stay.may.be.measured.in.

years.(Norton,.2000)..As.a.rule.the.demand.for.long-term.care.is.not.acute,.but.the.

consumer.has.relative.freedom.of.choice.in.deciding.where.to.seek.help,.provided.

that.supply.is.available..It.is.also.easier.for.the.consumer.to.evaluate.the.quality.of.

long-term.care.than.that.of.more.specialized.health.care.(Norton,.2000)..

The.supply.of.health.and.social.services.differs.from.that.of.other.commodities..

The. most. critical. differences. are. information. asymmetry,. uncertainty. and.

figure 2. Relations of demand, supply and use of health and social services.

Limited resourcess Need

Demand Supply

Use of health and social services

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externalities.(Sintonen,.Pekurinen,.&.Linnakko,.1997)..For.these.reasons.health.

care.markets.and.the.public.health.care.sector.are.regulated.by.the.government..

In.an.analysis.of.the.use.of.health.and.social.services,.it.is.not.easy.to.specify.

which. factors.represent.the.demand.side.and.which. represent.the.supply. side..

Usually.what.is.interpreted.as.demand.is.in.fact.a.combination.of.demand.and.

supply.(Norton,.2000)..For.example,.age.may.be.a.determinant.of.demand.for.

long-term.care,.but.if.access.to.long-term.care.varies.by.age,.it.is.also.a.determinant.

of.the.supply.of.long-term.care.

The.literature.of.use.and.costs.of.services.overlap,.for.costs.are.derived.from.

the.use.(C.=.p.*.q),.C.=.costs,.p.=.price.and.q.=.quantity.of.services..Therefore,.

even.though.the.present.analysis.does.not.extend.to.costs,.the.literature.review.

here.also.comprises.studies.that.look.into.both.the.use.and.costs.of.health.and.

social.services..

2.4 Health and social services for older people in finland

Services.for.older.people.can.be.considered.to.include.two.main.components:.care.

and.cure..Care.is.about.helping.people.with.their.daily.activities.and.personal.care,.

while.cure.has.a.stronger.medical.emphasis:.the.purpose.is.to.make.a.person’s.

health.better.or.to.palliate.symptoms..Cure.is.more.typically.provided.formally,.

while.most.care.is.informal..Distinctions.are.always.going.to.be.artificial,.but.

formal. care. services. are. usually. provided. in. the. social. sector. and. cure. in. the.

health.sector..Services.for.older.people.are.arranged.at.the.interface.of.health.and.

social.services,.and.they.may.come.under.different.branches.of.administration..

At. the. national. level,. health. and. social. care. delivery. is. regulated. by. the.

Ministry. of. Social. Affairs. and. Health. (MSAH),. which. issues. guidelines. and.

recommendations,.e.g..the.National.framework.for.high-quality.services.for.older.

people.(Ministry.of.Social.Affairs.and.Health.&.Association.of.Finnish.Local.and.

Regional.Authorities,.2008).to.the.municipalities.that.are.responsible.for.service.

provision.. It. also. has. overall. financial. and. supervisory. responsibility.. Central.

government. transfers. to. municipalities. were. formerly. earmarked. for. specific.

services,.but.today.municipalities.are.free.to.decide.how.to.allocate.these.funds.

(National. Research. and. Development. Centre. for. Welfare. and. Health,. 2006)..

Most.services.are.statutory.and.governed.by.different.laws.(Social.Welfare.Act.

710/1982.and.Primary.Health.Care.Act.66/1972)..However,.scarcity.of.resources.

often.makes.it.difficult.for.municipalities.to.meet.their.legal.obligations..There.

has.been.long-standing.discussion.on.the.introduction.of.separate.legislation.on.

services.for.older.people..A.new.Health.Care.Act.entered.into.force.on.1.May.2011..

The.basic.structures.of.care.for.older.people.will.remain.unchanged,.but.clients.

will.have.greater.freedom.to.choose.where.they.want.to.receive.care..

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Finland.is.divided.into.21.hospital.districts,.which.provide.secondary.care..

Each.hospital.district.has.a.central.hospital,.five.of.which.are.university.hospitals..

University.hospitals.produce.tertiary.care.as.well.as.some.secondary.care.in.their.

district..Most.hospital.districts.also.have.one.or.more.district.hospitals..

Responsibility.for.the.provision.of.health.and.social.services.for.local.residents.

rests.with.municipalities,.of.which.there.were.336.in.2011..Municipalities.may.

produce.the.services.themselves,.jointly.with.other.municipalities,.or.purchase.

them.from.another.public.or.private.(for-profit).or.third.sector.(not-for-profit).

service.producer..Users.may.also.purchase.the.services.they.need.directly.from.

the.private.or.third.sector;.these.purchases.are.partly.subsidized.by.the.Social.

Insurance.Institution.(SII)..Municipalities.have.significant.powers.and.autonomy.

to.plan.and.implement.their.services.as.they.best.see.fit.(Vuorenkoski,.Mladovsky,.

&.Mossialos,.2008),.and.indeed.there.is.much.variation.in.how.they.respond.to.

the.needs.of.their.residents.

For.the.most.part.older.people.use.the.same.health.care.services.as.other.age.

groups,.but.there.are.some.services.that.are.specifically.targeted.at.them..Acute.care.

is.provided.by.different.types.of.hospitals,.and.inpatient.wards.of.health.centres.

also.provide.long-term.care..Every.municipality.or.joint.municipal.authority.has.

a.health.centre.that.provides.primary.outpatient.and.inpatient.services..Health.

centre.inpatient.wards.allocate.some.60%.of.their.capacity.to.the.provision.of.acute.

care,.the.rest.is.allocated.to.the.long-term.care.of.older.people.(Kokko,.2009)..The.

share.of.acute.and.long-term.care.varies.between.health.centres.(Vuorenkoski.

et.al.,.2008)..Health.centre.inpatient.wards.play.an.important.part.in.the.care.

of.older.people:.91%.of.the.patients.at.these.units.are.65.years.or.older.(National.

Research.and.Development.Centre.for.Welfare.and.Health,.2006)..

Residential. homes. for. older. people. are. primarily. intended. for. long-term.

care,.but.they.also.admit.clients.for.shorter.stays.for.instance.for.the.duration.

of.an.informal.carer’s.leave..In.sheltered.housing.older.people.live.in.their.own.

apartments. and. can. purchase. services. according. to. their. needs.. Personnel. at.

ordinary.sheltered.housing.facilities.are.available.during.the.daytime.only,.but.

there. are. also. facilities. with. 24-hour. assistance.. Only. the. latter. facilities. are.

classified.as.long-term.institutional.care..

Older. people. living. in. their. own. homes. or. ordinary. sheltered. housing. can.

obtain. home. help. services,. home. nursing. and. support. services,. e.g.. meals. on.

wheels,.cleaning.or.transportation.services..

Private.health.care.mainly.comprises.ambulatory.care,.which.is.only.available.

in.larger.cities..The.private.sector.provides.about.16%.of.all.outpatient.visits.to.

physicians,.41%.of.visits.to.dentists.and.5%.of.inpatient.care.(Vuorenkoski.et.al.,.

2008)..The.capability.of.older.people.to.pay.is.improving,.and.they.are.now.in.the.

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position.to.buy.services.from.the.private.sector.if.the.supply.is.available.(Vaarama,.

2004)..

In.2002.three-quarters.of.all.care.services.for.older.people.were.provided.by.the.

public.sector,.the.remaining.one-quarter.by.the.private.sector.and.the.third.sector.

(Parkkinen,.2004)..The.roles.of.the.private.and.the.third.sector.are.different.in.

different.services..In.2010,.96%.of.inpatient.care.in.health.centres.was.public.and.

4%.private.(National.Institute.for.Health.and.Welfare,.2011)..Care.in.residential.

homes.was.mainly.(87%).produced.by.public.providers,.10%.by.the.third.sector.

and.only.3%.by.the.private.sector..The.major.provider.of.sheltered.housing.with.

24-hour.assistance.was.the.public.sector.(42%),.followed.by.the.third.sector.(32%).

and.the.private.sector.(26%)..No.exact.figures.are.available.for.home.nursing,.but.

it.is.primarily.produced.publicly..In.2003.76%.of.home.help.was.produced.publicly,.

10%.privately.and.14%.by.the.third.sector.(National.Research.and.Development.

Centre.for.Welfare.and.Health,.2004)..As.for.services.delivered.to.homes,.privately.

produced.services.are.mainly.used.for.smaller.needs.and.public.services.for.larger.

needs.(Vaarama,.2004)..There.is.some.inter-sectoral.cooperation,.but.overall.the.

service.field.tends.to.be.highly.fragmented,.and.according.to.National.Audit.Office.

of.Finland.(2010).the.planning.of.care.leaves.much.to.be.desired..Regardless.of.the.

sector.that.produces.the.services.for.older.people,.the.responsibility.for.service.

delivery.to.local.residents.rests.with.the.municipality...

Informal.care.is.help.provided.for.coping.with.daily.domestic.tasks.and.in.

everyday. life. as. well. as. care. and. prevention. of. diseases. by. a. spouse,. children,.

other.relatives.or.friends..Informal.care.is.typically.long-term.(Norton,.2000)..

The.evidence.suggests.that.among.older.people,.informal.care.is.a.more.common.

source.of.help.than.formal.care.(Anttonen.&.Sointu,.2006;.Blomgren,.Martikainen,.

Martelin,.&.Koskinen,.2006;.Vaarama,.2004;.van.Aerschot.&.Majanen,.2010)..In.

the.study.of.Blomgren.et.al..(2006).most.of.those.older.people.(≥70.years).who.

received.formal.help.also.had.access.to.informal.help,.but.very.few.received.formal.

help.only..However,.not.all.older.people.have.people.around.them.who.can.offer.

them.help..Older.men.living.alone.and.both.women.and.men.with.no.children.

were.found.to.receive.formal.help.only.(Blomgren.et.al.,.2006)..It.has.been.found.

that.older.people.with.children.or.a.spouse.have.better.access.to.formal.care.(Pot.

et.al.,.2009).

Financial.support.is.available.for.informal.care.providers.(Statute.318/1993,.

Act.of.Support.for.Informal.Care.937/2005.came.into.effect.on.1.January.2006)..

This.is.based.on.formal.agreements.signed.between.the.municipalities.and.the.

caregivers,.who.will.receive.payment.according.to.local.terms.and.conditions.as.

well.as.two.days.off.a.month;.on.those.days.the.patient.will.receive.care.through.

municipal. services.. In. 2005. support. for. informal. care. provision. was. provided.

to.the.carers.of.2.3%.of.people.aged.65.or.over.(Voutilainen.et.al.,.2007)..The.

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proportion.of.carers.eligible.to.receive.the.support.is.higher,.but.not.all.of.them.

apply.

It.has.been.suggested.that.generally,.informal.and.formal.care.are.substitutes.

for.each.other,.but.in.the.case.of.severely.disabled.people.they.complement.each.

other.(van.Houtven.&.Norton,.2004)..Commodities.or.services.are.substitutes.

if.increases.in.the.price.of.one.commodity.or.service.lead.to.an.increase.in.the.

demand.for.the.other.commodity.or.service.(A..J..Culyer,.2005)..Informal.care.

is.not.intended.as.a.substitute.for.all.kinds.of.formal.care..In.one.study.informal.

care.was.found.to.reduce.the.use.of.home.health.care.services.and.to.delay.nursing.

home.entry,.and.also.to.substitute.hospital.care.and.physician.visits.(van.Houtven.

&.Norton,.2004)..A.Finnish.study.found.that.informal.care.substituted.for.an.

estimated.11,400.inpatient.bed-day.in.2002.(Vaarama,.2004)..

Health. services. are. financed. by. municipalities. (35%),. central. government.

(24%),.the.Social.Insurance.Institution.(15%),.private.households.(20%),.employers.

(3%).and.others.(4%).(National.Institute.for.Health.and.Welfare,.2010)..User.fees.

account. for. a. variable. proportion. of. total. financing. depending. on. the. service.

in.question..In.2005,.user.fees.accounted.for.one-fifth.of.the.costs.of.home.care.

and.for.one-sixth.of.the.costs.of.residential.home.care.(National.Research.and.

Development.Centre.for.Welfare.and.Health,.2007)..User.fees.for.short-term.care.

are.usually.fixed..Fees.for.regular.home.care.are.based.on.the.overall.volume.

of.services.and.on.the.size.and.income.of.the.care.recipient’s.family..In.the.case.

of.long-term.institutional.care,.user.fees.are.based.on.the.client’s.ability.to.pay.

(National. Research. and. Development. Centre. for. Welfare. and. Health,. 2007)..

Private. health. care. and. prescription. medicines. are. partly. reimbursed. under.

National.Health.Insurance.(NHI),.which.is.based.on.compulsory.insurance.fees..

Sheltered. housing. residents. may. be. eligible. to. receive. an. allowance. from. the.

SII. to. cover. a. part. of. their. rent. and. service. fees. (Väisänen. &. Hujanen,. 2010)..

Municipalities.have.an.incentive.to.find.alternatives.to.their.own.service.provision.

and.in.this.way.to.shift.the.burden.of.financing.to.other.parties..For.instance,.in.

residential.homes.the.costs.of.patient.medication.is.covered.by.the.municipality,.

whereas.in.sheltered.housing.they.are.covered.under.the.NHI..(Häkkinen,.2005).

.Over.the.past.two.decades.services.for.older.people.have.failed.to.keep.up.

with.the.growth.of.the.elderly.population:.while.the.number.of.older.people.has.

continued.to.rise,.services.have.been.shrinking.(Parkkinen,.2002)..The.proportion.

of.people.aged.75.or.more.and.using.services.for.older.people.decreased.from.

1988.to.2000,.with.the.exception.of.the.use.of.sheltered.housing,.which.actually.

increased.(Vaarama.&.Voutilainen,.2002)..A.similar.trend.was.observed.from.

2000.to.2009.(National.Institute.for.Health.and.Welfare,.2011)..The.main.reason.

for.reduced.service.coverage.is.usually.thought.to.lie.in.the.lack.of.money,.but.

attitudes.and.values.also.come.into.play.(Vaarama,.2004)..

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Most.older.people.prefer.to.live.in.their.own.home..In.1992.the.Ministry.of.

Social.Affairs.and.Health.took.the.decision.to.start.moving.away.from.institutional.

care.towards.sheltered.housing.and.home.care.arrangements.(Ministry.of.Social.

Affairs. and. Health,. 1992).. Since. then,. the. proportion. of. older. people. in. long- term.care.has.remained.at.close.to.10%,.but.the.proportion.of.sheltered.housing.

residents.has.increased.and.the.use.of.institutional.care.has.decreased.(Kokko.&.

Valtonen,.2008;.Voutilainen.et.al.,.2007)..However,.home.care.has.not.been.found.

to.increase.to.offset.the.decrease.in.institutional.care.(Kokko.&.Valtonen,.2008)..

The.recession.of.the.1990s.also.had.an.effect.on.the.service.structure.and.the.

coverage.of.services.(Vaarama.&.Voutilainen,.2002)..

The.supply.of.home.services.in.particular.falls.short.of.current.service.needs..

The.resources.made.available.to.home.care.have.not.increased.in.line.with.targets.

(National.Audit.Office.of.Finland,.2010)..The.coverage.of.services.provided.to.

people.living.at.home.decreased.from.1990.through.to.2002,.when.coverage.started.

to.increase.(Vaarama,.2004)..Home.care.clients.are.increasingly.old.and.have.an.

increasing.number.of.disabilities..The.proportion.of.those.receiving.home.care.

services.up.to.several.times.a.day.has.increased,.while.those.receiving.less.visits.

has.decreased.(Kokko.&.Valtonen,.2008;.Vaarama,.2004)..The.proportion.of.home.

care.users.varies.in.different.regions.from.less.than.10%.to.17.4%.(Voutilainen.et.

al.,.2007)..Home.care.is.considered.a.cheaper.option.than.institutional.care,.but.

that.is.not.necessarily.the.case.if.it.is.necessary.to.arrange.a.number.of.visits.a.

day.or.other.services.to.support.those.living.at.home.(National.Audit.Office.of.

Finland,.2010)..

The.proportions.of.older.people.getting.support.for.informal.care.and.admitted.

to.sheltered.housing.with.24-hour.assistance.has.been.on.the.increase.(National.

Institute.for.Health.and.Welfare,.2011)..Responsibility.for.care.provision.has.been.

delegated.to.family.members,.and.priority.given.to.sheltered.housing..The.service.

structure.still.leans.towards.institutional.care.(Vaarama,.2004),.particularly.when.

sheltered.housing.with.24-hour.assistance.is.considered.a.form.of.institutional.

care.

The.National.framework.for.high-quality.services.for.older.people.(Ministry.

of. Social. Affairs. and. Health. &. Association. of. Finnish. Local. and. Regional.

Authorities,. 2008). also. recommended. reducing. the. level. of. institutional. care,.

especially.long-term.care.in.health.centres..A.working.group.(Ikähoiva).set.up.by.

MSAH.to.look.into.ways.of.developing.care.for.the.elderly.proposed.discarding.

the. fragmented. three-tier. 24-hour. care. system. in. favour. of. one-tier. 24-hour.

care,.and.furthermore.recommended.that.institutional.care.not.be.replaced.by.

institutional.solutions..The.working.group.concluded.that.preference.should.be.

given. to. homelike. housing. for. older. people. and. that. transitions. between. care.

facilities.be.minimized.in.situations.where.residents’.needs.were.changing..

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The.challenges.arising.from.population.ageing.will.affect.Finnish.municipalities.

at.different.stages..In.many.municipalities.the.number.of.older.people.has.already.

exceeded.the.projected.national.average.for.2030.(Vaarama,.2004)..The.old.age.

dependency.ratio.(i.e..the.number.of.older.people.aged.65.or.over.as.a.proportion.of.

working.age.population).varies.widely.in.different.areas.and.is.projected.to.exceed.

100%.by.2030.in.some.areas.(Parkkinen,.2002)..The.organization.of.services.for.

older.people.also.varies:.for.instance.the.coverage.of.institutional.long-term.care.

has.increased.in.40%.and.decreased.in.60%.of.Finnish.municipalities.(Kokko.&.

Valtonen,.2008)..

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3 Use and costs of health and social services at the end of life among older people

The.studies.reviewed.here.were.focused.on.the.use.and.costs.of.health.and.social.

services.in.the.last.years.of.life.among.older.people..The.services.included,.the.

age.limits.applied.and.the.follow-up.periods.all.differ.across.these.studies..The.

following. reports. the. main. results. of. these. studies,. which. are. summarized. in.

Appendix.tables.1–3..Health.service.use.at.the.end.of.life.has.also.been.studied.

among.younger.age.groups,.for.instance.at.the.age.of.≥18.years.(Jakobsson.et.al.,.

2007).and.all.ages.(Busse.et.al.,.2002)..Studies.dealing.with.the.last.year.of.life.of.

cancer.sufferers.or.other.people.with.a.terminal.illness.were.excluded.from.the.

review...

3.1 Impact of closeness of death

This.section.reviews.earlier.studies.dealing.with.the.use.and.costs.of.services.(1).

among.decedents.and.survivors.and.(2).monthly.service.use.in.the.last.year.of.life..

It. has. been. reported. that. HCE. is. several. times. higher. for. decedents. than.

for.survivors:.on.average.276%.higher.in.the.study.of.Experton,.Ozminkowski,.

Branch,.and.Li.(1996),.3–6.times.higher.in.the.study.of.McCall.(1984).and.13.5.

times.higher.in.the.study.of.Polder,.Barendregt.and.van.Oers.(2006)..Werblow.

et.al..(2007).found.that.HCE.was.5.times.higher.for.decedents.than.survivors.

one.year.before.death.and.two.times.higher.four.years.before.death,.and.Hoover,.

Crystal,.Kumar,.Sambamoorthi.and.Cantor.(2002).reported.that.HCE.was.more.

than.5-fold.for.the.last.year.of.life.as.compared.to.non-terminal.years..

Marked. differences. have. been. found. in. service. use.. Experton. et. al.. (1996).

reported.that.decedents.were.seven.times.as.likely.to.have.any.hospital.admission,.

four.times.as.likely.to.be.admitted.to.a.skilled.nursing.facility.and.twice.as.likely.to.

use.home.health.services.than.survivors..Decedents’.hospital.use.was.more.than.

twice.as.high.as.survivors’.in.the.study.of.Wolinsky,.Stump.and.Johnson.(1995)..

Among.those.who.had.hospital.episodes,.decedents.were.found.to.have.11.5.days.

longer.total.stays.than.survivors..Decedent.status.(decedent.=.1,.survivor.=.0).

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had.the.greatest.impact.of.any.variable.describing.hospital.resource.consumption.

(Wolinsky,.Culler,.Callahan,.&.Johnson,.1994).

Decedent.status.was.found.to.have.a.significant.effect.on.the.use.of.both.acute.

and.long-term.care.in.the.Netherlands.when.age.and.gender.were.adjusted.for.

(Pot.et.al.,.2009)..The.results.were.not.affected.by.adding.enabling.variables.(see.

Andersen. &. Newman,. 1973). to. the. model,. but. adding. need. variables. (disease.

and.disability.related).eliminated.the.effect.of.decedent.status.in.other.services.

than.long-term.institutional.care..In.Japan.decedents.were.found.to.have.a.higher.

probability.to.use.institutional.care.than.survivors,.but.there.was.no.difference.in.

expenditure.per.user.(Hashimoto.et.al.,.2010)..

The.cost.ratio.of.decedents.and.survivors.has.been.found.to.decrease.sharply.

with.age.(Häkkinen.et.al.,.2008;.Perls.&.Wood,.1996;.Polder.et.al.,.2006;.Serup- Hansen.et.al.,.2002)..In.the.study.of.Temkin-Greener.et.al..(1992),.the.health.care.

costs.for.younger.decedents.in.the.last.year.of.life.were.on.average.285%.higher.

than.those.for.survivors,.but.the.costs.for.the.oldest.(85.years.or.over).decedents.

were.only.35%.higher.than.those.for.the.survivors.of.their.age..In.the.use.of.acute.

care,.the.difference.between.decedents.and.survivors.was.greater.in.younger.than.

older.age.groups.(from.55–60.to.85–91.years).in.the.Netherlands.(Pot.et.al.,.2009)..

The.difference.has.diminished.with.age.because.the.probability.of.service.use.and.

the.expenditure.decreased.with.advancing.age.among.decedents.and.increased.

among.survivors.(Hashimoto.et.al.,.2010;.Lubitz.&.Prihoda,.1984)..In.the.use.of.

long-term.care,.on.the.other.hand,.the.difference.between.decedents.and.survivors.

was.actually.found.to.grow.with.increasing.age.in.the.studies.of.Pot.et.al..(2009).

and.Werblow.et.al..(2007)..

There.is.no.consensus.on.whether.the.effect.of.decedent.status.on.the.use.and.

costs. of. services. is. due. to. decedents’. diseases. and. disability,. or. whether. some.

other.mechanism.is.at.play..Rhee,.Degenholtz,.Muramatsu.and.Lau.(2009).found.

that.decedents.were.more.likely.to.use.care.and.that.they.received.more.hours.of.

both.formal.and.informal.care.than.survivors,.even.when.physical.and.cognitive.

disability.was.adjusted.for..According.to.Scitovsky.(1988).the.care.of.dying.older.

people.involves.additional.burdens.beyond.those.that.can.be.explained.on.the.

basis.of.health.status.alone..However,.Hogan,.Lunney,.Gabel.and.Lynn.(2001).

suggested.that.the.“high.cost.of.dying”.is.due.simply.to.the.cost.of.caring.for.

severe.illness.and.functional.impairment..In.their.study.decedents’.costs.were.

not.much.higher.than.those.of.others.who.had.similarly.complex.medical.needs..

In.addition.to.differences.between.decedents.and.survivors,.research.has.been.

undertaken.to.explore.the.effect.of.closeness.of.death.on.the.use.and.costs.of.

services.within.the.last.year(s).of.life.in.order.to.establish.the.exact.point.at.which.

use.and.costs.begin.to.increase.when.life.approaches.its.end.

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It.has.been.reported.that.costs.rise.in.the.very.last.month.of.life.(Liu,.Wiener,.

&.Niefeld,.2006)..In.the.USA.30%.of.all.Medicare.expenditure.(Lubitz.&.Prihoda,.

1984).and.in.the.Netherlands.36.5%.of.HCE.(Stooker.et.al.,.2001).in.the.last.year.

of.life.were.incurred.in.the.last.month..In.the.USA.the.increase.in.HCE.was.found.

to.start.24.months.before.death,.accelerating.from.6.months.up.to.the.last.month.

before.death.(Yang.et.al.,.2003)..In.a.Swiss.data.HCE.was.much.higher.in.the.last.

three.months.of.life.than.in.the.24–22.last.months.(Felder,.Meier,.&.Schmitt,.

2000)..Liu.et.al..(2006).found.that.Medicare.acute.care.(mainly.hospital).costs.rose.

dramatically.in.the.last.three.months.of.life.

In.Sweden.Larsson,.Kåreholt.and.Thorslund.(2008).reported.that.hospital.use.

started.to.increase.9.months.before.death..In.the.USA.it.was.found.that.total.

health.services.use,.dominated.by.hospital.use,.increased.seven.months.before.

death,.with.the.largest.increase.occurring.in.the.last.month.(Mukamel,.Bajorska,.

&.Temkin-Greener,.2002)..McCall.(1984).found.that.60%.of.care.(mostly.hospital.

care).in.the.last.year.of.life.was.provided.during.the.last.three.months,.and.Garber.

et.al..(1999).found.that.the.number.of.days.in.hospital.or.hospice.rose.sharply.

as. the. date. of. death. approached.. Long. and. Marshall. (2000). reported. that. the.

intensity.of.care.increased.in.all.age.groups.in.the.last.month.of.life..In.Japan,.

the.probability.of.using.hospital.inpatient.care.increased.month.by.month.before.

death,.as.did.expenditure.per.user,.but.decreased.in.the.very.last.month.of.life.

(Hashimoto.et.al.,.2010).

In.Sweden.the.use.of.institutional.care.was.found.to.increase.sharply.in.the.

last.6.months.before.death.(Larsson.et.al.,.2008),.but.the.effect.of.closeness.of.

death.has.been.found.to.extend.even.further:.in.Canada.the.use.of.nursing.home.

increased.steadily.for.the.last.four.years.of.life.(Roos,.Montgomery,.&.Roos,.1987)..

In.Japan.Hashimoto.et.al..(2010).found.a.decreasing.trend.in.institutional.care.

use.towards.the.end.of.life..Here.both.the.probability.of.using.institutional.care.

and.expenditure.per.user.remained.stable.in.the.last.year.until.the.second.last.

month.of.life.and.then.decreased.(Hashimoto.et.al.,.2010)..Medicaid².long-term.

care.costs.were.also.found.to.be.stable.for.the.last.year.of.life.until.the.very.last.

month,.when.they.decreased.(Liu.et.al.,.2006)..

Although.the.sharpest.increase.in.hospital.use.has.been.found.to.occur.during.

the.last.year.of.life,.there.are.also.indications.that.this.trend.continues.over.a.

longer.period..Hospital.use.doubled.from.the.fourth.to.the.second.last.year.of.life.

in.all.but.the.youngest.(45-64.years).age.group.in.the.study.of.Roos.et.al..(1987)..

Seshamani.and.Gray.(2004c).found.that.the.probability.of.hospital.use.increased.

from.year.16.before.death.and.quadrupled.from.the.second.last.to.the.last.year.of.

2. Medicaid.is.a.state.administered.health.insurance.programme.in.the.USA..It.is.available.

to.low-income.individuals.who.meet.certain.eligibility.criteria.(Centers.for.Medicare.and.

Medicaid.services,.2005)..

(31)

life..In.their.study.the.costs.among.those.who.were.hospitalized.also.increased.in.

the.last.11.years.of.life.

Age.has.been.found.to.modify.the.time.effect,.with.a.shorter.period.of.increased.

service.use.detected.among.the.oldest.than.among.younger.decedents.(Roos.et.al.,.

1987;.Seshamani.&.Gray,.2004c;.Temkin-Greener.et.al.,.1992).

3.2 Impact of age and gender

The.effect.of.age.on.the.use.and.costs.of.health.and.social.services.at.the.end.of.

life.has.been.extensively.researched..Three.differing.results.have.been.reported:.

use.and.costs.increase.with.advancing.age,.use.and.costs.decrease.with.advancing.

age,.or.use.and.costs.initially.increase.but.after.a.certain.threshold.age.start.to.

decrease..The.effect.of.age.on.costs.seems.to.depend.largely.on.which.services.are.

included.in.the.analysis..

The.studies.concluding.that.total.health.care.expenditure.(HCE).increases.with.

age.have.mostly.covered.nursing.home.or.long-term.care.expenditure.(Häkkinen.

et.al.,.2008;.Roos.et.al.,.1987;.Werblow.et.al.,.2007)..Several.studies.have.found.

that.the.use.of.institutional.long-term.care.increases.with.advancing.age.(Bickel,.

1998;.Bird,.Shugarman,.&.Lynn,.2002.Oct;.Häkkinen.et.al.,.2008;.Liu.et.al.,.2006;.

Lubitz.&.Prihoda,.1984;.Menec,.Lix,.Nowicki,.&.Ekuma,.2007;.Pot.et.al.,.2009;.

Yang.et.al.,.2003)..

Total.HCE.has.been.found.to.decrease.with.age.in.Switzerland.(Felder.et.al.,.

2000),.the.Netherlands.(Polder.et.al.,.2006),.the.USA.(Bird.et.al.,.2002;.Hogan.et.

al.,.2001;.Levinsky.et.al.,.2001;.Lubitz.et.al.,.1995;.Lubitz.&.Riley,.1993;.Shugarman.

et.al.,.2004;.Stearns.&.Norton,.2004;.Temkin-Greener.et.al.,.1992).and.Germany.

(Brockmann,.2002)..In.Finland.Häkkinen.et.al..(2008).showed.that.expenditure.

on. somatic. care. and. prescribed. medicines. decreased. with. age.. Levinsky. et. al..

(2001).concluded.that.about.80%.of.the.decrease.in.Medicare.expenditure.was.due.

to.less.aggressive.medical.care.with.advancing.age..

Acute.care.costs.were.found.to.be.higher.among.younger.old.people,.but.nursing.

home.expenditure.higher.among.older.olds.(Hoover.et.al.,.2002;.Liu.et.al.,.2006;.

Scitovsky,.1988;.Spillman.&.Lubitz,.2000;.Temkin-Greener.et.al.,.1992)..Similarly.

the.number.of.hospital.days.was.found.to.decrease.slightly.with.advancing.age,.

but.the.number.of.nursing.home.days.to.increase.dramatically.(Brock,.Foley,.&.

Salive,.1996)..

The.use.of.hospital.care.has.been.found.to.decrease.with.advancing.age.on.a.

number.of.indicators:.probability.of.use.(Bickel,.1998;.Brameld,.Holman,.Bass,.

Codde,.&.Rouse,.1998;.Menec.et.al.,.2007),.number.of.days.(Busse.et.al.,.2002),.

total. inpatient. resource. use. (Brameld. et. al.,. 1998),. number. of. care. episodes.

(Wolinsky.et.al.,.1995).and.intensity.of.care.(Long.&.Marshall,.2000)..

Health and Social Service Use Among Older People. The last two years of life